Therapeutic options for patients with status epilepticus in old age

Status epilepticus (SE) is a serious acute condition that requires early and targeted treatment. Especially refractory SE (RSE) as well as superrefractory SE (SRSE) are an interdisciplinary therapeutic challenge even in young subjects. In patients of older age, further relevant aspects have to be considered, which result on the one hand from deviating pharmacokinetics and dynamics and on the other hand from comorbidities, polypharmacy and possible medical treatment limitations or patient preferences. The aim of this article is to review these particular aspects in the context of SE care for patients in older age groups and to highlight potential therapeutic strategies beyond the scope of the current national guidelines. In particular, alternative routes of administration and possible conservative forms of escalation of treatment are discussed, which are of special importance in relevantly premorbid patients in whom intensive medical treatment would further increase the already high mortality of SE in old age. With different parenteral administration forms of benzodiazepines in SE as well as the now well-described use of other antiseizure medications, such as brivaracetam, perampanel, stiripentol, topiramate, and zonisamide in RSE and SRSE, adequate therapeutic options are also available for this vulnerable patient group. Nevertheless, increased attention should be paid to patient preferences and medical ethical aspects in the treatment of SE in older age, especially in view of the per se high mortality.